The Republican Party’s official position on health-care policy is incoherent — because its actual one is politically toxic.
Throughout last year’s Obamacare fight, Donald Trump, Mitch McConnell, and Paul Ryan assailed the law for leaving millions of people uninsured, and saddling others with sky-high deductibles — while pushing legislation that would have left 20 million more people uninsured, and saddled the average American with even higher deductibles.
The cause of this disconnect was plain: The GOP’s actual objection to Obamacare — that it raised taxes on the wealthy to subsidize health-care coverage for the poor and working class — does not resonate with a majority of the party’s own voters, let alone with the public at large. The ever-rising cost of health care, declining availability of full-time jobs with generous benefits, and soaring inequality has produced a broad, bipartisan consensus that the government has a responsibility to make health care more affordable — and that raising taxes on the rich is an acceptable means of doing so.
Thus, Republicans have to pretend that they share the Democrats’ commitment to providing all Americans with affordable health care — they just disagree about how to do so (and their preferred method just happens to involve cutting taxes on the rich and making health care less affordable for most Americans).
The GOP can either be honest about its position on health-care policy — that it is more important to cut taxes on the rich than it is to prevent working Americans from dying preventable deaths or suffering medical bankruptcies — and come across as evil, or, it can lie, and come across as nonsensical.
On Wednesday, the White House Council of Economic Advisers (CEA) opted for Door No. 2.
In an issue brief titled “Innovative Policies to Improve All Americans’ Health,” Trump’s CEA proposes no new policies to improve all Americans’ health. Instead, the economists argue that there is a lot more to promoting public health than just expanding access to insurance (which is true), and therefore, undermining government programs that expand access to health insurance will improve public health (which is nonsensical).
The second part of the argument is only implicit — but given the administration’s tireless efforts to kick people off of Medicaid and slash federal health-care spending, the authors’ intentions are unmistakable:
There are many determinants of health, but recent U.S. government health policy has mainly focused on one: expanding health insurance coverage through implementation of the Affordable Care Act (ACA). The ACA expansion covered fewer people than anticipated, and most of them gained coverage through Medicaid, which provides small, uncertain benefits and limited access to care. Moreover, the ACA imposed costly mandates and regulations that raised costs, diminished people’s choices, and forced them to buy insurance they neither wanted nor needed.
Health insurance is a positive factor in the lives of Americans, providing financial protection and peace of mind in case of serious illness. But the evidence shows that health insurance provided through government expansions and the medical care it finances affect health less than is commonly believed.
… The Administration has made efforts to move beyond government insurance expansions that provide uncertain benefits to only a small segment of the population and instead pursue initiatives that lower costs and improve the health of all Americans.
Here, the White House feels compelled to acknowledge that health insurance provides Americans with “financial protection and peace of mind.” But it doesn’t have the courage to aassert that those who can’t afford insurance don’t deserve those goods. So instead, the CEA contends that “government insurance expansions” are undesirable because they provide “uncertain benefits to only a small segment of the population.”
But if the problem with government-provided insurance is that it isn’t universal — and that the benefits are “uncertain” — then why can’t the government just change the program to cover everyone, and provide comprehensive, concrete benefits?
The authors never offer any explanation for why government-provided insurance is inherently subpar (perhaps they don’t offer one because the GOP’s core voters rely on a popular, government-provided insurance program). And their specific complaints with the contemporary government system do not lend themselves to “free market” solutions. Private-sector competition will never lead insurers to voluntarily serve people who are too poor to pay premiums, or too sick to be profitably covered. Similarly, the government is in a much better position to provide “certain” benefits than are private institutions.
It’s possible that by “uncertain benefits” the authors meant to suggest that it is uncertain whether providing people with government health insurance does them any benefit whatsoever. But they, themselves, stipulate that health insurance offers financial protection and peace of mind. So, that argument makes no logical sense — and also, has no empirical support. A recent, landmark study of Medicaid’s effects on public health in Oregon found that the program led to a giant reduction in the risk of depression, the near-elimination of financially ruinous health expenditures, improved diabetes care, and better self-reported levels of overall health.
Anyhow, the CEA eventually pivots to noting that Obamacare didn’t prevent the opioid crisis (which is banally true) and slyly suggesting that it might have even caused that epidemic (which is grotesquely false).
Health policy that is predominantly focused on expanding insurance coverage risks missing other policies that can improve the health of our citizens … The Administration is particularly concerned about the opioid crisis that exploded during the ACA expansion … The Administration has taken substantial steps to decrease the supply of prescription and illicit opioids and to increase treatment options.
Here, the White House tacitly refers to Senator Ron Johnson’s claim that the “Medicaid expansion may be fueling the opioid epidemic in communities across the country” — a baseless premise that the Senate nonetheless “investigated” last year. A moment’s glance at the timeline of the opioid crisis reveals this notion to be a nefarious fiction. As the New York Times explained last September:
OxyContin prescriptions for noncancer pain grew by a factor of almost 10 between 1997 and 2002, long before the A.C.A. was signed into law. Drug-related mortality rates doubled between 1999 and 2013, the year before most states expanded Medicaid.
Further, while it is true that drug-related deaths have grown more rapidly in expansion states than in other states, that more rapid growth started in 2010, before the A.C.A. expansion. This suggests that causes other than Medicaid are more likely.
But the CEA’s insinuation isn’t merely baseless; it’s also obscene. Medicaid didn’t cause the opioid crisis, but the program has ameliorated it, by serving as one of the top sources of funding for addiction treatment in the United States. The administration knows this — and has worked to cut its funding by $1 trillion anyway.
At other points, the CEA makes unobjectionable observations about the virtues of discouraging unhealthy behaviors, controlling health-care costs, and reducing the price of specialty drugs. But it does not offer a single concrete proposal on any of these fronts. And the administration’s actual health-care policies are aimed almost exclusively at undermining the Obamacare marketplaces and making it harder for poor people to enroll in Medicaid — an agenda that the CEA’s technocrats refuse to forthrightly defend, beyond suggesting, repeatedly and incoherently, that “government” insurance gave people “uncertain” benefits, so it doesn’t really matter if we take them away.
